Ruminations by a non-academic general surgeon from the heart of the rust belt.

Wednesday, February 10, 2010

Senator Murtha Dies Following Gallbladder Surgery

First of all, condolences to the family of Senator John Murtha who died recently following complications of gallbladder surgery. My thoughts are also with the surgeon in Maryland who performed the laparoscopic cholecystectomy. The death of a patient following routine elective surgery represents every surgeon's worst nightmare. The fact that it happened to a prominent American politician just exacerbates the stress and despair that the surgeon is probably feeling right now.

But I wanted to respond to a clip I watched earlier today from ABC News. In the video, Diane Sawyer (I know, you're supposed to say the lovely Diane Sawyer) interviews the ABC medical correspondent Richard Bessler, MD (trained as a pediatrician) about the possible causes of Senator Murtha's unfortunate outcome. Based on his explanations, she may as well have asked a 1st year medical student. According to Dr Bessler:

"to do this surgery, to remove the gallbladder, you need to separate it from the large intestine.....what may have happened, there may have been a small nick in the large intestine"

Now, what I think Dr Bessler is describing is an entity called a cholecysto-colonic fistula, which is very rare. For one thing, there are no natural attachments between the gallbladder and the large intestine. Certainly in cases of acute inflammation it is possible that an abnormal adhesion may form between the colon and gallbladder but these adhesions are typically very flimsy and easily divided; development of an actual connection between gallbladder and colon only occurs in cases of chronic inflammation over years and years. The likelihood that Murtha died from an injury to the colon is extremely low, statistically.

Most likely, Senator Murtha developed some sort of bile leak, either from the cystic duct stump or an actual injury to the common bile duct itself. Uncontained bile leakage throughout the abdominal cavity can lead to peritonitis, systemic inflammatory response syndrome (SIRS) and subsequent multiple organ failure/death. If there was a bowel injury, the most common source would be either the duodenum (often adherent to the neck of the gallbladder during the acute phase) or else small bowel adherent to the abdominal wall down by the umbilical port site (in placing the intial port, one can sometimes unwittingly cut into intestine that is stuck to the abdominal wall). Injury to the hepatic flexure of the colon would be much lower on my differential of possible causes.

I'm irritated because these are obvious points I'm making (from a surgical perspective). And here we have ABC News relying on the "expert testimony" of a pediatrician who works for the CDC. Dr Bessler, bless his heart, is obviously trying. You can tell that he looked at a human atlas and saw that the colon seems to be pretty close to the gallbladder. But his hypothesis is detached from any semblance of statistical likelihood. Why didn't ABC News ask, I don't know, maybe a SURGEON what the likely causes of Murtha's demise were? Is that asking too much? I know the guy is good looking and seems to handle himself well in front of the camera, but doesn't a news organization as influential as ABC News have an obligation to get their basic facts straight?

On another note.....posting has obviously been light. Probably will stay that way. Busy work and a crawling baby force a guy to have to eliminate certain indulgements.

I'm a 1st year medical student - and while we have no technical skills (yet), we are just 2 months removed from our Anatomy dissection. So even I could go on ABC News and say, 'No, perforation of the large intestine is not terribly likely.'

After a morning where a pediatrician in clinic asked one of my classmates if he knew what an antibody was, I feel the need to point out that some of us 1st years do, in fact, have our heads on straight.

I've enjoyed your blog through my first year - thank you for taking the time to share your work!

Nice post. makes you wonder what qualifies someone to be the one commenting on and dispersing information on medicine and health to the general public...I mean, think about how many other people saw that news report, believed it, or further - will use their personal response to it to make decisions regarding surgery. Kind of crazy.

Anyway, I don't normally respond to blogs but I just wanted to tell you how much I enjoy reading yours, and I am always happy to see when you have a new post that pops up in my blogger dashboard. I am now in my 4th yr. of med school and can definitely thank you for a few study breaks throughout the past few years!

by the way, I think your point is well taken: Interview actual experts for mass media. That being said, surgeons are way over represented on screen. The public assumes surgeons are the elite, and having FACS after your names seems to boost your street cred. That's why we have a cardiothoracic surgeon on Oprah giving tips on how to handle migraine headaches. e.g. Gupta, Gawande, Frist

Ah, so Dr. Bessler did say that. I was only half listening to the report and thought I heard wrong. It still amazes me how pigeon-holed people can be - to the point of losing basic knowledge. He needs to have a lifeline: "ask the expert".

Mobile baby means time to be sure your cell is always placed high and away... or one day a few months from now, it might end up in the toilet :o)

Associated Press reported that Rep. Bob Brady, a friend of Sen. Murtha, said that Murtha's large intestine was damaged during gallbladder surgery, and that he was readmitted on Jan. 31 with fever and infection. My guess would be an unrecognized cautery injury as the underlying cause.

Anon 2/11-That may be the case. But Dr Bessler either had an inside tip on what happened but described it in an incorrect, facile way....or he just got lucky with a wild conjecture. Either way, it dodn't come off very well....

Maybe Dr. Bessler was thinking the senator had an appendectomy? Either way, he's an attention whore for agreeing to go on national TV to comment on a completely different field of medicine than the one he practices.

One of the worst students in my medical school class had the aspiration of "medical journalism" as his main goal in life. It's these kinds of statements and knowledge that these kinds of idiots are the ones being asked questions that makes it hard for patients/ physicians to actually trust each other.

Jenny McCarthy is treated as an expert on vaccines. She is given equal time to babble non sequiturs to fawning debate hosts.

At the other end of the problem spectrum is Dr. Sanjay Gupta, who should understand the definition of brain death, but keeps telling people that they can recover from being brain dead. Maybe what he means is that the media will give you a platform for your pet conspiracy theory, even if you are brain dead. Or should that be especially if you are brain dead?

Because Senator Martha surgery I have put off my gallbladder surgery.I have been in pain off and on for two weeks now but the pain is getting worst so I have to do somthing. Is there another way to get rid of gall stones? Do I have to be put asleep if I go with the surgery?

To the anonymous person putting off their cholecystectomy... I think this is a bad idea. The longer you wait, the more difficult your operation could become. There really is no other way to get rid of troublesome gallstones. What happened to Murtha is unfortunate, but rare. While there are no guarantees, you'll probably do fine. You are best served getting it taken care of sooner, rather than later though.

I know this post is a much older one, but I'm getting my gallbladder taken out next week & my surgeon had given me a consultation telling me that the likelihood of a bowel injury is less than 1%. Although this is a common procedure, I'm very nervous because it's my first one... I'm at 30% of my ejection fraction, which they said is good enough to remove my gallbladder, however I have NO stones. I just feel like most surgeons just wanna open everyone up for the money. I'm hoping my assumption is also wrong. :\

I had my gallbladder removed six months ago. Everyone assured me complications are rare so I felt pretty comfortable I would have a normal outcome. The surgery went well and I was recovering nicely, then on the fourth day everything changed. I woke up throwing up and constantly gagging. I completely lost my appetite and was unable to eat. I've had a CT scan, Upper GI and small bowel test, and endoscopy done and all came back normal. My dr says its just my body adjusting to not having a gallbladder. Do you believe that? Could my surgeon have done something wrong? Any ideas???

This scares the hell out of me, Ive been dx with MS for 7yrs, jus had laproscopic gallbladder surgery two weeks ago. A weeks ago I developed an abcess in my bellybutton incision and am having an inflammatory reaction. Called my surgeons answering service immediately, the lady on the phone preceded to instruct me to "get some tweezers and pull on the pus filled mass"..........Uh, I think NOT! I insisted she speak to my surgeon. A couple of hours later she calls me back. The surgeon called me in some antibiotics and told her to tell me to "squeeze my incision and get all the pus out" WTH?!! These ppl are trying to kill me I swear! So I went in to my primary care doc who was very concerned, he drained it an packed it and gave me bactroban. Three days since and have developed another abcess.....idk what do :(

In certain circumstance the Gall bladder surgery Dubai specialist recommend gall bladder removal. As gall bladder is not an essential organ, you are able to lead a normal life. In the absence of gall bladder liver will produce and store bile, and release it into the intestine whenever necessary.

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